PAN AMERICAN
WORLD
HEALTH
HEALTH
ORGANIZATION
ORGANIZATION
XXIII Meeting XXVII Meeting Washington, D.C.
September-October 1975
Provisional Agenda Item 26 CD23/24 (Eng.) 5 September 1975 ORIGINAL: SPANISH
FIRST INTERSECTORAL MEETING ON'THE'HEALTH OF'MAN'IN THE AMERICAS
PROGRESS REPORT OF THE DIRECTOR
At its 72nd meeting, the Executive Committee approved Resolution V, in which it recommended to the XIX Pan American Sanitary Conference that it consider the possibility of holding an Intersectoral Technical Meeting on the Health of the Man in the Americas, which would explore the possibilities of promoting the coordinated intersectoral use of resources to improve the well-being of the most seriously unprotected population.
In its Resolution XLII, the XIX Conference asked the Director to convoke a working group to define the most suitable criteria and methods for orienting the activities of the countries, with a view to strengthening intrasectoral coordination in health and developing intersectoral collabora-tion; thus, programming for the sector and the third Ten-Year Health Plan would be based on intersectoral collaboration.
The XIX Conference also requested the Director to report to the Directing Council on the progress of the activities programmed, and in-structed the Council, on the basis of the Director's report, to state its opinion regarding the advisability of holding the proposed intersectoral meeting.
It became necessary, for financial reasons, to eliminate the working group, but the Director, wishing to follow through with this proposal, felt it would be appropriate to prepare the attached study, which contains an analysis of the characteristics and possibilities for intersectoral collabo-ration in connection with the objective established by the Executive Committee of promoting the coordinated intersectoral use of resources in order to im-prove the well-being of the unprotected population.
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some experiments in intersectoral health planning that are being carried out in the Region, the study reaches the conclusion that one way of achieving the objective established by the Executive Committee would be to complement the coverage extension programs now being prepared by the countries with integral food and nutrition programs based on the developmenl: of agricultural produc-tion and the improvement of the income of campesino;: and farmers, and with the appropriate components of community development programs.
In order to become operational, this conclusion must be supported by a set of carefully selected strategies and methods, bhecause each country is faced with complex problems of its own with regard to intersectoral collaboration.
It is suggested that, to define these strategies and methods, a small working group composed of high-level experts in the fields of public health, health planning and economic and social planning be convoked. Such a working
group would be charged with formulating concrete proposals on the most ap-propriate strategies and methods for achieving the objective established by
the Executive Committee, using the attached study as a reference paper. The Bureau would transmit these recommendations to the countries for their
consideration and for adaptation to the different national situations. Thus, by 1978 a number of countries would already have acquired significant
experience in the field and, consequently, the question of intersectoral collaboration aimed at promoting the coordinated use of resources to improve
the well-being of the most unprotected population could be the subject of
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the Technical Discussions at that year's Conference.INTERSECTORAL COLLABORATION
Problems and Prospects
If we are to succeed in meeting the health needs, let alone in fulfilling the health
expectations, of total populations rather than of small privileged groups, we must ensure that health care is fully integrated with the other economic and social sectors involved in community development.
H. Mahler, Director General of WHO. Address to ECOSOC, 9 July 1975
A. INTRODUCTION
The Concept
The need for intersectoral collaboration in order to increase the effectiveness of health care has not been questioned. At the theoretical level, this need is self-evident, since it is nothing but a reflection of
the complementarity of the factors or conditions essential to survival. If one or more of these factors is missing, e.g., adequate nutrition, ed-ucation, shelter, environmental sanitation, etc., the effectiveness of health care will be seriously limited, and even cancelled out, within a short time. This may be seen very clearly where the poor health of a population is a reflection of the living standards of the very low income
sectors1 rather than of a lack of health services; in such cases, even the most complete and high quality health care services can be rendered useless
if they do not go hand in hand with the delivery of the other basic goods and services essential to subsistence.
The Coverage Goal of the Ten-Year Health Plan
The above observations are particularly meaningful in the Region of the Americas, since one of the fundamental goals of its Ten-Year Health Plan is to extend coverage of minimum services to the entire unprotected
population. The Executive Committee of PAHO reaffirmed the importance of this goal at its 74th Meeting, when it recommended to the Directing Council that it ask governments to place special emphasis on coverage of the rural population, utilizing to that end the experience accumulated in the Region
1At the high- and middle-income levels, health still depends on the afore-mentioned complementarity, but at those levels the problem of ensuring
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and all possible human resources of the community, and that it ask PASB to give maximum priority to the expansion of health services destined to achieve total coverage (Resolution XIII).
This represents a clear commitment on the part of governments to design policies and programs and assign resources with a view to providing minimum services to the populations not currently covered, and a commitment
on the part of PAHO/WHO to provide the advisory services that the countries need in order to achieve this goal. Since the population that is not now covered by health services is by definition the lowest income population in the countries and is located for the most part in the rural areas that are not easily reached geographically, economically and culturally, and in the underprivileged urban areas, it seems obvious that interdisciplinary and intersectoral collaboration provide the tools essential for ensuring the achievement of the aforementioned goal.
The Need For a New Approach
With specific reference to the problems of extreme poverty in the rural areas, at the 59th Session of the United Nations Economic and Social Council, held last July, the Director General of WHO made, inter alia, the following remarks: "A new approach to improving the material and social well-being of rural people is needed in developing countries--one that embraces policies aimed at improving social welfare on the most equitable basis possible in rural areas, and that is built irto the pattern and organization of production. Planning to increase Froduction should be geared to these policies, and production and consumption should be planned first in physical terms. By this I mean the provieion of a minimum "package" of social goods and services, including health promotion, to bring about a sustained reduction of the worst aspects of rural toverty."
The Unified Approach of the United Nations
This new approach is closely related to the concerns of the United Nations Economic and Social Council and of the United Nations General
Assembly, which, by Resolutions 1494 (XLVIII) and 2681 (XXV), respectively, put underway a research project on a "Unified Approach to Development
Analysis and Planning." This project was carried out by the United Nations Social Development Research Institute in cooperation with the Department of Economic and Social Affairs and the Economic Commission for Latin America; its outcome may be found in the final report submil:ted by the Secretary-General to the Commission on Social Development1 al: its January 1975 session.
'Report on a Unified Approach to Development Analysis and Planning, E/CN.5/519, 5 Dec. 1974, United Nations, ECOSOC.
In its Report, which consists of a complete study of the many com-plex problems involved in this matter, the Institute stresses that, begin-ning with its terms of reference, the unified approach implies the need for intersectoral along with regional integration, as well as the need for participation, and proposes that a new concept be accepted which goes
beyond the traditional concept of development planning and is essential for the achievement of a unified approach. This new concept is that of capacita-tion as a basis for policy formulacapacita-tion and project evaluacapacita-tion, and as an essential tool for bringing about a unified approach to development plan-ning. The Institute proposes its concept of capacitation as the necessary substitute for and, to a certain extent, the correlate of--in the field of social planning--the traditional concept of planning the growth of material production, and assigns it the basic function of establishing now the
conditions or capacities that will enable a given society to meet its needs in the future.
The meaning of this function can be better understood by comparing it with the traditional economic planning function of "defining and control-ling the future," which is based on the assumption that the goals of a plan
can be precisely defined and measured; that causal relationships, especially between the means and the ends, are clearly known or can be known, and that
the future can be controlled through the plan.
These assumptions may be valid for the planning of material produc-tion, but clearly they are not valid for the planning of social change. The latter requires an attitude of constant search and reorientation based on a process the elements of which are the diagnosis of existing weaknesses and potentialities, the design and implementation of suitable policies, and
the constant monitoring of the course of development in order to refor-mulate policies.
As may be seen, the orientation proposed by the Institute is very similar to the integral approach that is well known in the field of public health, and will undoubtedly strengthen the promotion of intersectoral co-operation started by the Governing Bodies of PAHO/WHO.
B. REQUIREMENTS AND CHARACTERISTICS OF INTERSECTORAL COLLABORATION
The Institutional Problem
Evidently, this proposal should not be understood as an undertaking initiated by the health sector and carried out by it in collaboration with other sectors. Above and beyond institutional jealousies, which are
easily aroused, it must be remembered that it is not a question of one
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This conception is the result not only of the! very nature of the idea of intersectoral collaboration but also of the fact that, as is stated in the epigraph, "we must ensure that health care is fully inte-grated with the other economic and social sectors involved in community development."
In other words, when the health sector states the need for inter-sectoral collaboration to increase the effectiveness of its work, what it is really doing is inviting the other sectors to undertake a collective effort to increase the effectiveness of the work of all sectors, i.e., to contribute more effectively to the integral development of the community. As is emphasized below, this means a more human and fair concept of social
progress, the promotion of which appears to be a natural responsibility of the health sector.
Effectiveness and Efficiency
The direct justification for intersectoral collaboration is to be found in the greater effectiveness to which it lead3. Nevertheless, the efficiency it makes possible is equally important, since there is an
economy of resources in relation to the magnitude of the results obtained. This efficiency may even be more important than the effectiveness because, without it, the idea of meeting the needs of the large masses of under-privileged rural and urban populations would be meaningless in the coun-tries with a greater shortage of resources, which are the ones that feel the problem most sharply.
There are two reasons why the intersectoral approach brings about significant increases in efficiency or economy of aztion. In the first place, it is a "package" of basic goods and services the cost of which is considerably lower than it would be if they were provided separately, in view of the savings in overhead costs, which in turn reduce the unit cost; since a very large demand is met, there are also savings in production. In the second place, since it is aimed at meeting tae needs of the entire uncovered underprivileged population, which in many countries is larger than the population currently covered, the intersectoral approach allows for no alternative but to give up the high-cost traditional solutions aimed at meeting the needs of the middle- and high-income sectors and to replace them with less expensive "minimum" solutions, which may be far from meeting the traditional patterns of quality but which are equally if not more
effective in real terms since they are offered in packages which are en-hanced by intersectoral complementarity.
The Concept of Capacitation
Moving from theory to reality, a question immediately arises as to the operational feasibility of intersectoral cooperation as described above. Such misgivings would seem to be well founded, since experience
has shown that,almost without exception, not much has been achieved by several projects of intersectoral cooperation. This has sometimes been due to a lack of resources or to excessively ambitious goals, or to impractical solutions; in other cases, it has been due to institutional rigidity. The fact is that most past attempts at intersectoral collaboration have quickly met with failure or have survived precariously into a stage where they have
reflected unfavorably on the idea and made it difficult to defend and promote it.
This experience reflects real problems the existence of which cannot be overlooked. Adequate solutions to them must be found.
This is where the concept of "capacitation" proposed by the United Nations Institute for Social Development Research could be applied. This concept was devised to overcome obstacles to change that originate in
institutional and structural factors and in people's habits, prejudices and attitudes, by creating the conditions necessary to change these factors and to enable the people themselves to learn to overcome their limitations.
These conditions may be quite varied, ranging from formal personnel training programs and the use of legal tools and regulations to the design of schemes or expedients which by changing certain aspects of a situation can encourage the participation of individuals who might have refused it had the traditional situation been maintained. In the final analysis, the most usual obstacles to action reflect a lack of motivation among those who
should carry it out, and this is where the greatest effort must be made. To this end, it must be borne in mind that motivation is the result of widely divergent mechanisms of rewards and punishment, whether economic, emotional, legal, or personal, and it is usually possible to use combina-tions which reinforce each other.
C. SOME EXAMPLES
An Integral Nutrition Plan
One example that adequately illustrates the type of operation that has been commented on is the national food and nutrition plan drawn up recently by one of the countries in the Region. This Plan covers six programs which, taken together, involve the initiation of a process aimed
at solving within reasonable periods of time the serious nutritional problem of that country. The six programs of the plan are as follows:
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- The development of research studies to adapt certain varieties for production on small farms;
- The promotion of integral rural development, by providing
sup-port to campesinos with scarce resources through technical assistance, credit and electrification programs, the
construc-tion of silos and storage centers, access zoads, aqueducts and sewage systems, and schools, plus the strengthening of medical care programs, especially mother and child care;
- The expansion of credit for the development. of commercial enterprises;
- The financing of agroindustries; and
- The promotion of fisheries production.
Second, a program for promoting the production of processed foods of high nutritional value, which would encourage the development of a fairly
large industrial sector and the large-scale production of new,highly nutri-tious, low-cost food products, processed in the country by the technological research institute.
Third, a program for organizing and improving the food marketing system that would mitigate seasonal fluctuations in prices and reduce the differences between prices for producers and consumers.
Fourth, a program of nutritional education, stressing the field of mother and child care, which would operate at three levels: mass
communica-tions, various non-formal educational activities, and formal education at all levels.
Fifth, a program for improving the biological: utilization of food through the strengthening of mother and child care programs, vaccination against contagious diseases, and basic rural sanitation programs.
Sixth, and last, a program of direct nutritional protection for the lowest income groups of the population, which for miny reasons receive
few or none of the benefits of the above five programs and which are the groups most seriously affected by nutritional defic:encies. This program will be carried out through subsidized food distribution, possibly through the existing commercial distribution network.
suitable for implementing intersectoral collaboration, since only a divi-sion such as the national planning office would have the coverage and the scope required to ensure that the plan is compatible with other ongoing or programmed activities and to coordinate a joint effort wherein each sector makes its contribution within the framework of the overall effort.
The Nutrition Plan and the Unified Approach
The above is only a "general outline" of the plan and not a detailed description, as such details were not available at this writing. The
following comments, which will undoubtedly have been covered when the details are drawn up, are not to be construed as a criticism of the plan; they are only meant to better illustrate the nature of the unified approach implicit in intersectoral collaboration. There are two comments to be made:
First, the scheme places little emphasis on real resources, partic-ularly the human and organizational resources to be used to carry out the plan. Second, the question of evaluating the progress of the plan also seems to have been overlooked.
In a plan which is drawn up taking into account the fact that social change is usually quite independent of the best-planned projects of social engineering, the description of the human and organizational resources to be used to achieve the goals is as important as the goals themselves. In economic planning, which deals with the growth of material production, the problem of human and organizational resources tends to be given less atten-tion because there is usually an organized labor market, most of the deci-sions necessary for carrying out the plan depend upon the mechanisms of the market, and the application of policies is the responsibility of the
agencies specialized in the matter. These are the main features that enable economic planners to think that the future can be controlled by the plan. But we know very well that this is not the case when changes must be made in things such as the habits of farmers, mothers and consumers, and when the achievement of this purpose is contingent upon joint and coordi-nated action by the bureaucracies of different institutions and sectors.
In such cases, if the plan is to be realistic, it is essential to identify in detail the human resources to be used, their activities and the way in which they will be organized, the channels and modalities of their
relation-ships, and the way in which they will be administered. Otherwise, the plan will be nothing but wishful thinking.
Closely linked with the above is the problem of evaluation, i.e., of constant control over the performance of the human resources involved.
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scope of any corrective measures that should be takEn. In a very real sense, what we are speaking of here is the "administration" of the plan, not the traditional periodic evaluation and control which lead to adjust-ments in the plan, but rather the evaluation and conLtrol of its day-to-day operation, which is what determines its results, Again, this is different from economic planning, which is based on known and stable causal relationships which make it possible to space evaluation periods; social planning, on the other hand, calls for continuous evaluation because it is based on unknown causal relationships, if there are any at all, and on behavior that is rarely stable. In other words, the process of evaluating the plan becomes identified here with the process of
administering it, and should more appropriately be Labeled as a process of "evaluation-supervision."
Coverage Programs Now Underway
To date, the governments of no less than six countries in the Region are proceeding with the preparation of coverage programs to
provide minimum services to the uncovered population. These programs are based on the concept of capacitation and, consequently, the problems of human resources requirements and of evaluation-supervision are receiv-ing maximum attention.
Essentially, these programs are set up on the basis of defining the tasks that can be performed by the staff likely to be available,
with the support of an appropriate evaluation-supenrision mechanism and I within the framework of a regionalized system of services that facilitates
the referral of patients.
Since the staff that will be providing the m:.nimum services
belongs to the communities and has a low level of education, the starting point of the programs will be the training of this staff. Such training
is considered as a process to be continued, by stages, indefinitely.
As the main function of the basic staff is to help the population change their habits at several levels of daily life (nutrition, child
care, home economics, personal hygiene and environmental sanitation, etc.), the program will progress at the rate at which the population becomes capacitated in these subjects, which will a"so be a process of
indefinite duration.
Since the basic staff will have shared the same habits it is sup-posed to help change, it will not be very efficient professionally and will constantly be subject to regression. Consequently, the program
cannot function without appropriate evaluation-supervision mechanisms, without which it will be impossible to make any progress in the task of
capacitating, which is the basic object of the programs.
There is another feature of these programs that must be stressed: since the minimum services provided must be offered to the entire popula-tion, the staff providing them has to do so through direct contact with the families. This staff is therefore an ideal channel for bringing to the population the "package" of basic goods and services required to improve their standard of living.
This brings us once more to the entire problem of the intersectoral collaboration that is essential if the idea of delivering a "package" of goods and services is to be made a reality. If, as in the past, the health sector limits itself to delivering the minimum services in its own field, including nutrition and environmental sanitation, the coverage program will soon fail because the nutrition component will be lacking
its foundation, which is the increase of agricultural production, and the beneficiary population will not see any significant improvement in their standard of living because the ingredient of improved productivity, essential for the population to increase its consumption beyond the
field of health, will be missing. In other words, even modern programs of coverage extension that have been carefully drawn up within the framework of the new concept of capacitation run the risk of quickly becoming sterile if they are not integrated into broader schemes of
intersectoral collaboration.
The examples described above clearly show the advisability of having a scheme combining a national food and nutrition plan, like the one mentioned, with a coverage extension program. In such a combination, the national plan's program for improving the biological utilization of foods merges and becomes identified with the coverage extension program; and the basic staff of the latter takes charge of all or part of the
work of the nutrition plan that calls for direct contact with the families.
The picture will be complete if to this combination we add the necessary components of comunity development, thus covering the rest of the components of the "package."
D. A PROPOSAL FOR ACTION
The above comments cover the elements necessary for drawing up a concrete proposal for action. Basically, there are three such elements:
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Second, a broad program of food and nutritic.n the goal of which would be to ensure that agricultural production ant the productivity of
campesinos and farmers grows to the extent necessary to increase the supply of foods and the real purchasing power of the rural population. In other words, a plan that would ensure the material supply of the nutrition component of the coverage program, at the same time raising the income of the rural population so as to enable it to increase its consumption in other areas in which it is deprived,,
Third, programs of community development to complement the above, adding the components of education, housing, shelter, recreation, etc., which are necessary for the basic social well-being of the population.
The proposal is to promote a combination of these three types of programs, in mixtures that would logically be different for each country, in every case taking the basic staff from the healt:h coverage programs. This staff would, on the one hand, serve as a contact and distribution channel for the food and nutrition plan and, on the other, as a field assistant and agent for the community development programs.
A combination such as this makes it possible to bring together the three factors that are essential in order for :he social planning effort to be translated effectively into a better :3tandard of living for the population:
- the material supply of the goods and services that make up the package;
- the financing, particularly in terms of higher income for campesinos, which is necessary to enable them to increase their purchasing power;
- the tool, made up of the staff of the health coverage programs that is necessary to deliver the services, and in some cases the goods that make up the basic package.
Naturally, this social planning proposal is not conceived as being independent of economic planning, which is essential to ensure an
increase in the income of the urban population and the diversification of the material production brought about by technological progress. But it is somewhat more than merely complementary to economic planning, because its incorporation into the picture of development planning means
the addition of two elements the absence of which is to a large extent responsible for the inability of traditional planning to find suitable answers to the present problems of underdevelopment. These elements are, in the first place, the human dimension that is added when action is concentrated on the effort of capacitating the population to solve its own problems and better meet its needs and, in the second place, the
